SERF

2. W O R K S H O P G Christine Fehrenbach Respiratory Nurse Specialist

3. Bronchiectasis Chronic dilatation of one or more bronchi The bronchial wall becomes damaged as a consequence of earlier inflammation and infection of the bronchi or neighbouring lung tissue

4. Causes Severe infection especially in childhood TB, Whooping cough, measles, pneumonia Rheumatoid arthritis recurrent infections Male infertility � ciliary dysfunction Ciliary dyskinesia co existing sinusitis Hypogammaglobulinaemia Obstruction Tumour, foreign body, external compression

7. Signs and symptoms �Rattly cough Sputum on change of position Occasional small haemoptysis Exacerbations, fevers, breathlessness, pleurisy, wheeze Chest examination localised inspiratory crackles Finger clubbing

9. Investigations Clinical history Examination Sputum culture and observation Radiography - CXR CT scan

10. Management Physiotherapy daily Antibiotics � sputum culture prolonged courses intravenous Airway inflammation � inhaled steroids Airflow limitation - bronchodilator Surgery Disease progression leads to respiratory failure Immunoglobulin deficiency � IV products Localised areas may be resected

11. Interstitial Lung Disease Hypersensitivity to an organic antigen, resulting in an inflammatory response in the alveoli The antigens that cause this type of reaction are usually between 1 and 5 microns in diameter Less common in smokers The risks are real, eg about 10-20% of people who are in regular contact with pigeon will develop bird fanciers lung

13. Presentation Symptoms occur about 4 - 8 hour following exposure to the antigen and include: cough, breathlessness, headache, fever, muscle ache and feel generally unwell. Medical examination may reveal crackles and wheezes when the patient inhales and the x-ray may show diffuse interstitial shadowing, but may be normal. Blood tests for lgG antibodies e.g. �avian precipitins� are positive. Lung function tests show a reduction in lung volume, and a decrease in the movement and gases across the alveolar membrane

14. Tests and investigations X-ray show fibrosis - with shadowing more marked in the upper areas of the lung Chest auscultation may reveal inspiratory crackles and may be late inspiratory �squawk� (Ogilvie, 1982) Spirometry � restrictive pattern Blood for �precipitins� is positive

15. Treatment: Avoidance of exposure to allergen, e.g removal of pigeons or budgies from the home Avoidance measures e.g. wearing protective clothing Where there is intermittent exposure to birds, the use of face masks has been shown to significantly reduce the symptoms experienced by the patient The use of oral steroids has been shown to be helpful in the short term. The long term use of steroids for this type of illness is less clear.

17. Other Causes Drugs Anti Inflammatory agents Recreational drugs Anti � Arrhythmic � Amiodarone Antidepressants - Dothiepin

18. Cryptogenic fibrosing alveolitis Uncommon � becoming more prevalent Occurs in late middle age � male predominance Cause unknown � but related to metal/wood dusts viral infections Widespread fibrosis of the lung parechyma

20. Signs and symptoms Progressive breathlessness Dry cough Clubbing Fine inspiratory crackles Restrictive spirometry Central cyanosis Peripheral oedema Ground glass appearance on CT

22. Treatment Corticosteroids (40-60 mg for 2/12) 40% respond Immunosuppressants (Azothioprine, Cyclophosphamide) Oxygen Opiates Palliation Median survival � 3.5 years

24. Asbestos Inhaled asbestos fibres passing via lymphatics or penetrating across pleural space. Pleural plaques � clinically silent Diffuse pleural thickening � sob due to restricting thoracic movement Asbestos � chronic airway inflammation Mesothelioma � tumour of mesothelial cells of the pleura Lung cancer � asbestos exposure increases risk

26. Mesothelioma Males aged 50 � 70 Progressive breathlessness Visceral chest pain Chest examination � pleural fluid Outlook poor � median survival 12-18 months Palliation Industrial injury benefit

28. Sarcoidosis A multi-system disorder characterised by the presence of non-caseating granulomatus lesions. More common in Caribbean black, Irish ethnic origins.

29. Sarcoid can affect any organ but a Pulmonary presentation is common Maybe Asymptomatic cough � non productive. Sob. Acute presentation lethargy joint aches skin rash � erythema nodosum Bilateral hilar lymphadeopathy on CXR most important differential diagnosis lymphoma Blood tests � ACE Bronchial biopsy

31. Treatment Aim of treatment - suppress inflammation and prevent fibrosis Symptomatic Corticosteroids Other Methotrexate Azothioprine

32. TuberculosisUK 150 Years ago 1:8 deaths 1980 Uncommon in UK due to better housing, early detection & better treatments World Now Last year more deaths from TB than anytime - 8,000 per day

34. Last 20 years increasing in UK 30% 7,000 cases per year 3,000 of those in London 1:10,000 of the population 350 deaths

35. Symptoms Appetite lost � weight Persistent cough Phlegm Tired Fever � night sweats Aching pleuritic chest pain

36. TB Spread TB lungs or larynx Droplet infection Prolonged repeated contact Only 10% develop clinical disease But not at that time Active later when weakened

37. 1-5% Develop primary disease Unnoticed resolves without treatment Can reactive later

38. Latent TB Infection No symptoms Cannot spread TB Positive tuberculin skin test Can develop disease later

40. Diagnosis Tuberculin test � mantoux CXR Sputum

41. Treatment Isoniazid Rifampicin Pyrazinamide Ethambutal Rifampicin Isoniazid

42. Drug Resistance Main cause incomplete treatment

43. Medication always supervised by specialist service Non infectious - two weeks

44. Screening contacts Rare for children to be infectious

45. High Risk Close contacts Visited, lived or worked in high rates TB Children of parents whose country origin has high TB rate Weakened immune system

46. Homeless Poor overcrowded Prison Addicted drugs / alcohol Young and old

47. National TB Action PlanOctober 2004 Control by Promptly recognising & treating Treatment completion BCG � high risk Health promotion Concentrating activity on at risk

48. BCG Vaccine Travel 1/12 in high risk countries Babies in high risk areas

49. Lung Cancer Edward VII

50. Causes 90% Cigarette smoking

51. 20% Smokers develop disease Genetics Environment Social Deprivation

53. Clinical Presentation 10% - No signs New cough or change in existing Haemoptysis Inspiratory stridor Pain Weight loss Lassitude Finger clubbing

54. Investigations CXR CT scan Bronchoscopy Bloods

56. Treatment Surgery Chemotherapy Radiotherapy Palliative care

57. Small cell carcinoma 20% Non small cell Adenocarcinoma 40%

58. Pre laser

59. Stents

60. Secondaries Brain

61. Breathlessness Drain effusions Steriod trial Breathing techniques Non pharmocological Morphine � oral & nebulised Anxiolytic

63. Haemoptysis Radiotherapy � external Brachytherapy Endobronchial cautery

64. Pain Bone pain � nsaid opiate Radiotherapy Neural pain - steroids

65. Anorexia Small frequent meals Increase spice / herb use Steroids Anti inflammatory drug

66. Cough Oral opiate Nebulised lignocaine

67. Metastatic Spread to Lungs Renal Melanoma Breast Ovary Gut Colon

68. Chronic Cough Post viral bronchial hyper-reactivity Chronic rhino � sinusitis Cardiac failure Reflux Infections

69. Full drug history including over the counter and herbal remedies Detailed occupational history searching for exposures

70. Breathlessness Within minutes � PE pneumothorax M.I. cardiac rhythm disturbance dissecting aneurysm acute asthma Hours or days � pneumonia pleural effusion LVF, asthma, blood loss, lobar collapse, muscle weakness Weeks � Infiltration � sarcoid, alveolitis malignancy. Pneumonia, MND, main airway OB. Anaemia, valvular dysfunction Months � same as weeks + obesity asbestos � related conditions Years � COPD heart value dysfunction obesity